EFTA00597453.pdf

FLOS CREDIT CARD AUTHORIZAION FORM Customer Name Company Name Billing Address City/State/Zip Credit Card # Expiration Date Security Code Billing Tel# Fax# Sales Order / Invoice / Account Number Amount to be Charged We require written authorization to charge your credit card. Your credit card details are to be provided above and reference to the order, invoice or account number this is to be applied to and total amount to be charged. Your signature indicates your understanding and agreement to FLOS USA's complete terms and conditions of sale, as well as your authorization for FLOS to charge you credit card in the amount as stated above. Please sign and fax this form back to us for processing. For FLOS Showroom orders, please fax to 212-941-4763 For FLOS USA office orders, please fax to 718/875-3473 Your order will be processed upon receipt of this signed agreement. Thank you. Signature Date FLU USA, Inc. 110 York Street, 5th Floor. Brooklyn, NY 11201 tel (718) 875-3472 fax (718) 875-3473 EFTA00597453